Download Bringing Patient-Centered Care to Patients with AUD (JAMA)

Opinion
Editorials represent the opinions of the authors and JAMA
and not those of the American Medical Association.
EDITORIAL
Bringing Patient-Centered Care to Patients
With Alcohol Use Disorders
Katharine A. Bradley, MD, MPH; Daniel R. Kivlahan, PhD
Alcohol use disorders (AUDs) are common, chronic conditions affecting more than 10% of US adults.1 Alcohol use disorders include a spectrum of problems due to impaired control over drinking and are a
major contributor to disabilRelated article page 1889
ity and death in the United
States. 2 However, patients
with AUD receive poorer-quality care than patients with any
other common chronic condition.3 Most patients with AUD do
not receive treatment, and medications for AUD are particularly underutilized. 4 The systematic review and metaanalysis by Jonas et al5 in this issue of JAMA has the potential
to increase awareness and use of pharmacotherapy for AUD.
The most important benefit of this review, however, will be if
it leads to more patient-centered care for AUD.
Patient-centered care and shared decision making are
essential for delivery of high-quality mental health and substance use disorder treatments.3 Shared decision making
requires a dialogue between patients and clinicians aimed at
(1) helping patients better understand their medical conditions and the need to make treatment decisions; (2) providing information about the benefits and adverse effects of
treatment options; (3) supporting patients while they clarify
their values and preferences and make a decision, even if
for no treatment; and (4) providing support while patients
implement their decisions.6,7 For patients with impaired
decisional capacity due to their illness, shared decision
making includes working with family, caregivers, or other
people who support the patient. Patient decision aids,
which provide up-to-date information on treatment options
and support patient-clinician communication about patient
preferences, are often used to support shared decision making and increase patient-centered care.8
Current medical management of AUD is usually in stark
contrast to concepts of patient-centered care. In the United
States, patients with AUD are typically offered referral to a
single type of AUD treatment—group-based, abstinenceoriented treatment programs relying on the 12-step principles of Alcoholics Anonymous (AA). Although many patients report benefit from these programs, most are not staffed
by clinicians who can prescribe medications to treat AUD and
most do not offer evidence-based behavioral treatments.9 In
addition to medications that improve drinking outcomes,5 at
least 4 types of one-on-one behavioral treatments for AUD are
effective: cognitive behavioral therapy, motivational enhancement therapy, behavioral couples therapy, and 12-step
facilitation.10,11 Moreover, no single behavioral treatment is su-
perior to all others. This is exactly the type of situation when
shared decision making is most valuable.7 However, many
health care professionals do not realize there are treatment options for AUDs. As a result, most patients are offered referral
to a single treatment, ie, programs based on 12-step principles, without consideration of patient preferences.
The review by Jonas and colleagues5 provides critical information about the efficacy and adverse effects of AUD pharmacotherapy needed for shared decision making and patient
decision aids. The authors evaluated 122 randomized trials and
1 cohort study (total 22 803 participants). Most of the studies assessed acamprosate (27 studies, n = 7519), naltrexone (53 studies, n = 9140), or both, which are approved by the US Food and
Drug Administration (FDA) for the treatment of AUD. Jonas and
colleagues report that the efficacy of the oldest and best known
FDA-approved medication for AUD—disulfiram—was not supported by randomized placebo-controlled trials, whereas 4
medications—naltrexone, acamprosate, topiramate, and
nalmefene—improved drinking outcomes. Most studies evaluated AUD medications when added to repeated behavioral interventions in patients who were abstaining when the medication was initiated. Mimicking the behavioral interventions used
in these studies in routine clinical practice could prove challenging. For example, one of the simplest behavioral interventions required 9 visits over 16 weeks,5 more frequent contacts
than are typically offered in primary care management of other
common medical and psychiatric conditions.12 Future research is needed on the efficacy of medications for AUD when
patients want to reduce drinking but do not have a goal of abstaining and to determine whether medications have efficacy
when provided without frequent behavioral interventions.
Shared decision making for AUD can be integrated into primary care. Primary care clinicians should assess AUD severity, medical and psychiatric comorbidities, reasons patients
may or may not want to change their drinking, and whether
they want help doing so. When establishing the diagnosis of
AUD, it is important to note that AUD is no longer divided into
alcohol abuse and dependence but is now recognized as a single
continuum. The new Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) diagnostic criteria for AUD rely on
a count of 11 criteria, with severity assessed based on the number of criteria a patient meets: mild (2-3), moderate (4-5), and
severe (6-11) AUDs.13,14 Clinicians and patients should discuss
ambivalence toward change; patient goals (eg, abstinence vs
decreasing drinking vs no change); preference for groupbased, one-on-one, or medication treatments or some combination; and differences in the privacy and cost of different
jama.com
JAMA May 14, 2014 Volume 311, Number 18
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Department of Veterans Affairs User on 05/13/2014
1861
Opinion Editorial
treatments. Some patients may prefer the privacy of mutual
help groups or community treatment programs that are not
documented in electronic health records. Patients with mild
AUD (2-3 criteria) can be offered behavioral therapies, mutual
help (eg, AA), and usual AUD treatment programs. Patients
meeting 4 or more criteria can be offered medications in addition to behavioral therapies. Those who are not yet interested in changing might be willing to engage in counseling
aimed at helping them consider the effects of drinking on their
lives and health (eg, motivational enhancement therapy). Patient decision aids can support shared decision making about
AUD treatment.
Patient-centered management of AUD will need to be integrated into both primary care and general mental health care.
Patients with uncomplicated AUD can be managed in primary care by integrated primary care mental health teams,
whereas patients with more complex AUD or those experiencing severe effects might benefit from mental health specialty
care. However, providing shared decision making and caring
for patients with AUD as part of primary or mental health care
will require increased clinical capacity. Innovative new systems of team-based care for AUD15 will be needed to meet the
demands of engaging patients in AUD care, assessing the severity of their AUD and comorbidity, offering them evidencebased treatments, and monitoring response to treatment.
ARTICLE INFORMATION
Author Affiliations: Group Health Research
Institute, Seattle, Washington (Bradley); Center of
Excellence in Substance Abuse Treatment and
Education, Seattle, Washington (Bradley); Health
Services Research and Development, Veterans
Affairs Puget Sound Health Care System, Seattle,
Washington (Bradley); Veterans Health
Administration, Washington, DC (Kivlahan);
Department of Medicine, University of Washington,
Seattle (Bradley); Department of Health Services,
University of Washington, Seattle (Bradley);
Department of Psychiatry and Behavioral Sciences,
University of Washington, Seattle (Kivlahan).
Corresponding Author: Katharine Bradley, MD,
MPH, Group Health Research Institute,
Metropolitan Park E, 1730 Minor Ave, Ste 1600,
Seattle, WA 98101 ([email protected]).
Conflict of Interest Disclosures: Both authors
have completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest. Dr
Bradley reported having grants pending from the
National Institute on Alcohol Abuse and Alcoholism
(NIAAA) and Group Health and owning stock in
Johnson and Johnson, AbbVie, and Pfizer. Pfizer
makes topiramate, which is included in the review
by Jonas et al and mentioned in this editorial. No
other disclosures were reported.
Funding/Support: This work was supported in part
by the NIAAA (R01AA018702) and the Department
of Veterans Affairs.
Role of the Sponsor: The funders had no role in the
preparation, review, or approval of the manuscript.
Disclaimer: The views expressed in this article are
those of the authors and do not necessarily reflect
the position or policy of Group Health Research
1862
Although primary care and mental health clinicians will
eventually share in the management of AUD, general mental
health clinicians should take the lead in incorporating evidence-based AUD treatments into their care. This will require
support from addiction medicine colleagues because many
general mental health clinicians do not currently provide treatment for AUD. However, with support they can offer both medications and effective behavioral therapies for AUD and promote integration of AUD care into primary care settings.
Moreover, primary care clinicians might be reluctant to provide care for AUD if their mental health colleagues are not yet
comfortable managing AUD.
Treatment of AUD is considered an essential health benefit under health care reform. More patients with AUDs will
have insurance, which could increase their access to evidencebased treatments for AUDs. 16 The article by Jonas and
colleagues5 should encourage patients and their clinicians to
engage in shared decision making about AUD treatment options. By identifying 4 effective medications for AUD, the authors highlight treatment options for a common medical condition for which patient-centered care is not currently the
norm. Patients with AUDs should be offered options, including medications, evidence-based behavioral treatments, and
mutual support for recovery. Moreover, patients should expect shared decision making about the best options for them.
Institute, Group Health, the Department of
Veterans Affairs, University of Washington, or
NIAAA.
Additional Contributions: We acknowledge our
colleagues—researchers and clinicians, as well as
patients and their families—who have collaborated
on research and grants related to improving
patient-centered care for alcohol use disorders. The
ideas expressed in this article build on the work of
this entire team.
8. Stacey D, Légaré F, Col NF, et al. Decision aids for
people facing health treatment or screening
decisions. Cochrane Database Syst Rev.
2014;1:CD001431.
9. Carroll KM. Dissemination of evidence-based
practices. Addiction. 2012;107(6):1031-1033.
REFERENCES
10. Alcohol-use disorders. National Institute for
Health and Care Excellence. http://publications.nice
.org.uk/alcohol-use-disorders-diagnosis
-assessment-and-management-of-harmful-drinking
-and-alcohol-cg115/guidance. Accessed April 24,
2014.
1. Dawson DA, Goldstein RB, Grant BF. Differences
in the profiles of DSM-IV and DSM-5 alcohol use
disorders. Alcohol Clin Exp Res. 2013;37(suppl
1):305-313.
11. Management of substance use disorder. VA
Office of Quality and Performance.
http://www.healthquality.va.gov/guidelines/mh/sud
/index.asp. Accessed April 11, 2014.
2. US Burden of Disease Collaborators. The state of
US health, 1990-2010. JAMA. 2013;310(6):
591-608.
12. Katon WJ, Lin EH, Von Korff M, et al.
Collaborative care for patients with depression and
chronic illnesses. N Engl J Med. 2010;363(27):26112620.
3. Institute of Medicine. Improving the Quality of
Mental Health Care for Mental and Substance-Use
Conditions. Washington, DC: National Academies
Press; 2006.
4. Harris AH, Oliva E, Bowe T, Humphreys KN,
Kivlahan DR, Trafton JA. Pharmacotherapy of
alcohol use disorders by the Veterans Health
Administration. Psychiatr Serv. 2012;63(7):
679-685.
5. Jonas DE, Amick HR, Feltner C, et al.
Pharmacotherapy for adults with alcohol use
disorders in outpatient settings. JAMA.
doi:10.1001/jama.2014.3628.
6. Légaré F, Witteman HO. Shared decision making.
Health Aff (Millwood). 2013;32(2):276-284.
7. Barry MJ, Edgman-Levitan S. Shared decision
making. N Engl J Med. 2012;366(9):780-781.
13. Hasin DS, O’Brien CP, Auriacombe M, et al.
DSM-5 criteria for substance use disorders. Am J
Psychiatry. 2013;170(8):834-851.
14. American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders. 5th ed.
Washington, DC: American Psychiatric Association;
2013.
15. Oslin DW, Lynch KG, Maisto SA, et al. A
randomized clinical trial of alcohol care
management delivered in Department of Veterans
Affairs primary care clinics versus specialty
addiction treatment. J Gen Intern Med.
2014;29(1):162-168.
16. McCrady BS. Health-care reform provides an
opportunity for evidence-based alcohol treatment
in the USA. Addiction. 2013;108(2):231-232.
JAMA May 14, 2014 Volume 311, Number 18
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Department of Veterans Affairs User on 05/13/2014
jama.com